Does the length of the biliary limb influence medium-term laboratory remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass in morbidly obese patients?

A Meta-Analysis Comparing RYGB with Long Biliopancreatic Limb (BPL) Versus Long Alimentary Limb (AL) in Groups with Equal or Nearly Equal Combined Bypass Lengths (Combined BPL and AL Lengths): Does Switching Seats Enhance Weight Loss?

It is well-established that extending either the biliopancreatic limb (BPL), the alimentary limb (AL), or both, results in increased combined bypass (CB) length, which in turn leads to enhanced weight loss and potential nutritional deficiencies due to heightened malabsorptive effects. However, a key question remains: Assuming no change in CB length, does altering BPL length affect outcomes? To address this question, we examined studies comparing long BPL and long AL (short BPL) while maintaining equal or nearly equal CB lengths. We conducted this systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We performed a meta-analysis on weight loss outcomes, adverse events and safety-related outcomes, gastrointestinal complaints, and nutritional outcomes at the 2-year mark.

Long Biliopancreatic Limb Roux-En-Y Gastric Bypass Versus One-Anastomosis Gastric Bypass: a Randomized Controlled Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the gold standard in bariatric surgery. The one-anastomosis gastric bypass (OAGB) procedure, first introduced by Dr. Rutledge, has demonstrated a 25% greater weight loss efficiency than the traditional Roux-en-Y gastric bypass (RYGB) procedure due to the substantially longer biliopancreatic limb (BPL).

AIM OF THE STUDY

The current work aimed to compare the outcomes of OAGB and long BPL RYGB regarding weight loss and comorbidity resolution.

PATIENTS AND METHODS

This randomized controlled trial was done at our institution between September 2019 and January 2021. Patients who were candidates for bariatric surgery were randomly and equally allocated to two groups. Group A underwent OAGB, while group B underwent long BPL RYGB. Patients were followed up for 6 months postoperatively.

RESULTS

This study included 62 patients equally allocated to OAGB or long BPL RYGB, with no dropouts during follow-up. At 6 months, there was no statistically significant difference between the two groups regarding postoperative BMI (P = 0.313) and the EBWL (P = 0.238). There was comparable remission of diabetes mellitus (P = 0.708), hypertension (P = 0.999), OSA (P = 0.999), joint pain (P = 0.999), and low back pain (P = 0.999). Seven patients in the OAGB group experienced reflux symptoms (P = 0.011), which were managed by proton pump inhibitors.

CONCLUSION

Extending the BPL in RYGB provides weight loss and comorbidity remission comparable to that of OAGB. Some OAGB-related reflux cases remain a concern. However, they were sufficiently controlled with PPIs. Due to OAGB superior technical simplicity, long BPL RYGB should be preserved for cases whom are more risky for bile reflux.

SMALL INTESTINAL L CELL DENSITY IN PATIENTS WITH SEVERE OBESITY AFTER ROUX-EN-Y GASTRIC BYPASS

BACKGROUND:

Enteroendocrine L cells can be found in the entire gastrointestinal tract and their incretins act on glycemic control and metabolic homeostasis. Patients with severe obesity and type 2 diabetes mellitus may have lower density of L cells in the proximal intestine.

AIMS:

This study aimed to analyze the density of L cells in the segments of the small intestine in the late postoperative of Roux-en-Y gastric bypass in diabetic patients with standardization of 60 cm in both loops, alimentary and biliopancreatic.

METHODS:

Immunohistochemistry analysis assays were made from intestinal biopsies in three segments: gastrointestinal anastomosis (GIA= Point A), enteroenteral anastomosis (EEA= Point B= 60 cm distal to the GIA) and 60 cm distal to the enteroenteral anastomosis (Point C).

RESULTS:

A higher density of L cells immunostaining the glucagon-1 peptide was observed in the distal portion (Point C) when compared to the more proximal portions (Points A and B).

CONCLUSIONS:

The concentration of L cells is higher 60 cm distal to enteroenteral anastomosis when comparing to proximal segments and may explain the difference in intestinal lumen sensitization and enterohormonal response after Roux-en-Y gastric bypass.

Standard Biliopancreatic Limb (50 cm) Roux-en-Y Gastric Bypass Versus Long Biliopancreatic Limb (100 cm) Roux-en-Y Gastric Bypass in Patients with Body Mass Index 40-50 kg/m2: a Randomized Prospective Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a widely performed procedure worldwide especially with the presence of associated medical conditions. Patients with body mass index (BMI) 40-50 kg/m² are at more risk of weight regain and relapse of comorbidities. There is a controversy on the optimum alimentary (AL) and biliopancreatic (BPL) limb lengths to be used in RYGB to achieve weight loss and remission of comorbidities without causing nutritional deficiencies in those patients.

STUDY DESIGN

hundred-and-fifty patients with BMI between 40 and 50 kg/m² were divided equally into 2 groups undergoing standard RYGB (S-RYGB) with AL:150 cm and BPL: 50 cm and long biliopancreatic RYGB (L-RYGB) with AL: 100 cm and BPL: 100 cm. BMI, % of total weight loss (%TWL), effect on diabetes (DM), hypertension (HTN), dyslipidemia, and nutritional statuses were recorded at 1, 2, and 3 years.

RESULTS

Only 64/75 patients in S-RYGB and 57/75 patients in L-RYGB completed the study. L-RYGB had faster weight loss, higher %TWL, and less BMI than S-RYGB with the maintenance of achieved weight. L-RYGB had better control of DM and dyslipidemia than S-RYGB. There were no significant differences in nutritional status between S-RYGB and L-RYGB rather than lower levels of calcium and Hb and higher levels of PTH in L-RYGB yet they remain within the normal range.

CONCLUSION

The application of L-RYGB helps in achieving faster weight loss for a longer period with better remission of associated comorbidities as DM, HTN, and dyslipidemia in patients with BMI 40-50 kg/m² but with effects on the nutritional status.

One Anastomosis Gastric Bypass Versus Long Biliopancreatic Limb Roux-en-Y Gastric Bypass

Background

Roux-en-Y gastric bypass (RYGB) is one of the most effective bariatric procedures. The study aimed to explore the value of lengthening the biliopancreatic limb (BPL) in RYGB compared to the outcome of one-anastomosis gastric bypass (OAGB).

Methods

This prospective study included morbidly obese patients divided into two groups. The RYGB group (n = 36) was subjected to long biliary limb Roux-en-Y gastric bypass (LPRYGB), and the OAGB Group (n = 36) had one anastomosis gastric bypass. During follow-up, weight, BMI, percentage of excess body weight loss (%EBWL), resolution of obesity-related comorbidities, and quality of life (QoL) were evaluated.

Results

There was no significant difference in weight and BMI after 3 and 6 months. At 12-month follow-up, weight loss was significantly higher in the OAGB group. After 12 months, the two groups showed significant improvement of comorbid conditions without significant difference between the two groups. The Qol was significantly higher in the LPRYGB group 3, 6, and 12 months after surgery compared to the OAGB group.

Conclusions

Extending the BPL length in RYGB to 150 cm is as effective as OAGB in remission of comorbidities, including diabetes. It was also equally effective in weight reduction in the short term. OAGB was more efficient in weight reduction and a significantly faster operation. LPRYGB showed a better QoL of life 1 year after surgery.

Graphical abstract

Effect of Roux-en-Y Gastric Bypass with Different Lengths of Biliopancreatic and Alimentary Limbs for Patients with Type 2 Diabetes Mellitus and a BMI < 35 kg/m2: 5-Year Outcomes in Chinese Patients

PURPOSE

There have been no definite conclusions about the biliopancreatic limb (BPL) and alimentary limb (AL) lengths in Roux-en-Y gastric bypass (RYGB) operations for different populations and BMIs. Western scholars have performed many studies on the lengths of the BPL and AL in patients with a BMI ≥ 35 kg/m². However, for diabetic Chinese patients with BMI < 35 kg/m², few people have compared the effects of different BPL and AL lengths on patient prognosis.

PATIENTS AND METHODS

Clinical data were collected prospectively and analyzed retrospectively for 87 patients with type 2 diabetes (T2DM) who underwent RYGB with a BPL of 50 cm and an AL of 50 cm (BPL50/AL50) or with a BPL of 100 cm and an AL of 100 cm (BPL100/AL100) and who were followed up for 5 years.

RESULTS

The cohort included 42 patients in the BPL50/AL50 group and 45 patients in the BPL100/AL100 group. At 5 years, there were significant differences in BMI, total weight loss (TWL%), glycosylated hemoglobin, and homeostasis model assessment insulin resistance between BPL50/AL50 and BPL100/AL100 (P < 0.05). Diabetes remission rate of the BPL100/AL100 group was significantly higher than that of the BPL50/AL50 group. Diabetes remission at 1 year after surgery correlated with the length limb (BPL + AL), duration of diabetes and TWL%. There was no difference in complications between BPL50/AL50 and BPL100/AL100.

CONCLUSIONS

RYGB with BPL100/AL100 is a safe and effective treatment for diabetic patients with a BMI < 35 kg/m² and offers significant improvement in weight loss and glycemic control.

Comparison of Conventional Methods for Bowel Length Measurement in Laparoscopic Surgery to a Novel Computer-Assisted 3D Measurement System

Purpose

Accurate laparoscopic bowel length measurement (LBLM), which is used primarily in metabolic surgery, remains a challenge. This study aims to three conventional methods for LBLM, namely using visual judgment (VJ), instrument markings (IM), or premeasured tape (PT) to a novel computer-assisted 3D measurement system (BMS).

Materials and Methods

LBLM methods were compared using a 3D laparoscope on bowel phantoms regarding accuracy (relative error in percent, %), time in seconds (s), and number of bowel grasps. Seventy centimeters were measured seven times. As a control, the first, third, fifth, and seventh measurements were performed with VJ. The interventions IM, PT, and BMS were performed following a randomized order as the second, fourth, and sixth measurements.

Results

In total, 63 people participated. BMS showed better accuracy (2.1±3.7%) compared to VJ (8.7±13.7%, p=0.001), PT (4.3±6.8%, p=0.002), and IM (11±15.3%, p<0.001). Participants performed LBLM in a similar amount of time with BMS (175.7±59.7s) and PT (166.5±63.6s, p=0.35), but VJ (64.0±24.0s, p<0.001) and IM (144.9±55.4s, p=0.002) were faster. Number of bowel grasps as a measure for the risk of bowel lesions was similar for BMS (15.8±3.0) and PT (15.9±4.6, p=0.861), whereas VJ required less (14.1±3.4, p=0.004) and IM required more than BMS (22.2±6.9, p<0.001).

Conclusions

PT had higher accuracy than VJ and IM, and lower number of bowel grasps than IM. BMS shows great potential for more reliable LBLM. Until BMS is available in clinical routine, PT should be preferred for LBLM.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05620-6.

The Effect of Standard Versus Longer Intestinal Bypass on GLP-1 Regulation and Glucose Metabolism in Patients With Type 2 Diabetes Undergoing Roux-en-Y Gastric Bypass: The Long-Limb Study

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) characteristically enhances postprandial levels of glucagon-like peptide 1 (GLP-1), a mechanism that contributes to its profound glucose-lowering effects. This enhancement is thought to be triggered by bypass of food to the distal small intestine with higher densities of neuroendocrine L-cells. We hypothesized that if this is the predominant mechanism behind the enhanced secretion of GLP-1, a longer intestinal bypass would potentiate the postprandial peak in GLP-1, translating into higher insulin secretion and, thus, additional improvements in glucose tolerance. To investigate this, we conducted a mechanistic study comparing two variants of RYGB that differ in the length of intestinal bypass.

RESEARCH DESIGN AND METHODS

A total of 53 patients with type 2 diabetes (T2D) and obesity were randomized to either standard limb RYGB (50-cm biliopancreatic limb) or long limb RYGB (150-cm biliopancreatic limb). They underwent measurements of GLP-1 and insulin secretion following a mixed meal and insulin sensitivity using euglycemic hyperinsulinemic clamps at baseline and 2 weeks and at 20% weight loss after surgery.

RESULTS

Both groups exhibited enhancement in postprandial GLP-1 secretion and improvements in glycemia compared with baseline. There were no significant differences in postprandial peak concentrations of GLP-1, time to peak, insulin secretion, and insulin sensitivity.

CONCLUSIONS

The findings of this study demonstrate that lengthening of the intestinal bypass in RYGB does not affect GLP-1 secretion. Thus, the characteristic enhancement of GLP-1 response after RYGB might not depend on delivery of nutrients to more distal intestinal segments.

Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters

INTRODUCTION

Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising.

METHODS

All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m², were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL.

RESULTS

A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m². Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133-156 cm) for RL and 100 cm (95% CI 97-113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238-260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course.

CONCLUSION

Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.

Short versus long biliopancreatic limb in Roux-en-Y gastric bypass surgery for treatment of type 2 diabetes mellitus

Introduction

Although laparoscopic Roux-en-Y gastric bypass (RYGB) is still widely accepted as a valid procedure in the treatment of obesity and type 2 diabetes mellitus (T2DM), there continues to be a significant controversy about how long the Roux and biliopancreatic limb should be bypassed for optimum results.

Aim

To assess the effect of a longer biliopancreatic limb (BPL) length on glycemic control after RYGB in T2DM patients.

Material and methods

Eighty-four patients with uncontrolled T2DM who underwent RYGB between May 2010 and April 2017 were collected from the prospectively designed database. Forty patients (S-BPL group) received BPL lengths ≤ 50 cm, including 30 cm (n = 1), 40 cm (n = 1), and 50 cm (n = 38). Forty-four patients (L-BPL group) received 100 cm BPL. Anthropometry, serum glucose and lipid metabolic parameters were measured at baseline and 1, 3, 6, 12, 24 and 36 months after surgery.

Results

Comparing the two groups, there were no significant differences in anthropometric and biochemical measures, except the weight and body mass index, which were higher in the S-BPL group (85.91 ±20.32 vs. 76.25 ±16.99, p = 0.038; 31.87 ±6.61 vs. 28.7 ±4.29, p = 0.005) compared to the L-BPL group. The body weight, glucose and lipid metabolic parameters decreased over time and then remained essentially stable from the first year in both groups. Two years after surgery, the remission (HbA_1c% ≤ 6%) of T2DM was 31.2% in the S-BPL group and 37.5% in the L-BPL group (p = 0.685).

Conclusions

With consistent total small bowel bypass (AL + BPL) lengths, lengthening of the BPL from 30 to 100 cm did not affect the post-RYGB glycemic control and weight loss.

The role of alimentary and biliopancreatic limb length in outcomes of Roux-en-Y gastric bypass

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is one of the safe and easily reproducible bariatric procedures.

AIM

To evaluate the effect of biliopancreatic limb (BPL) and alimentary limb (AL) length on weight loss outcomes after RYGB.

MATERIAL AND METHODS

This retrospective cohort study included 313 morbidly obese patients who underwent primary laparoscopic RYGB 2009-2015. Patients' BPL and AL lengths were categorized into three groups: group 1 (BPL: 50 cm and AL: 150 cm), group 2 (BPL: 150 cm and AL: 50 cm), and group 3 (BPL: 100 cm and AL: 100 cm). Data were provided from the Iranian National Obesity Surgery Database. The generalized estimating equations method was used to assess the effect of limbs length on %excess weight loss (%EWL).

RESULTS

Mean ± standard deviation age and body mass index (BMI) of 252 patients were 38.55 ±10.24 years and 45.8 ±4.77 kg/m2, respectively. Totally, 172 (68.3%, BMI of 46 ±5 kg/m2), 48 (19%, BMI of 45.12 ±4.26 kg/m2), and 32 (12.7%, BMI of 45.43 ±4.23 kg/m2) were in group 1, 2, and 3, respectively (p = 0.44). The results showed that the choice of different limb lengths had no significant effect on %EWL over 12 months follow-up (p = 0.625) adjusted for baseline BMI (p = 0.25). Mean %EWL in the patients with longer BPL and shorter AL was 5.43% (1.91, 8.95) higher in comparison to the patients with shorter BPL and longer AL during 36 months postoperatively adjusted for baseline BMI (p = 0.002).

CONCLUSIONS

During 12 months after RYGB, %EWL was not associated with BPL or AL length. However, during 36 months postoperatively, the patients with longer BPL had a significantly higher %EWL in comparison to the patients with shorter BPL.

Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length

BACKGROUND

Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass.

METHODS

Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated.

RESULTS

Median presurgery body mass index was 46 (25th-75th percentile: 43-51) kg/m2. Medians (25th-75th percentiles) for alimentary limb length were 125 cm (100-150), for biliopancreatic limb length were 50 cm (50-60), and common channel length were 410 cm (322-520). Statistics for ratios to the small bowel length were 0.23 (0.18-0.27) for alimentary limb, 0.09 (0.07-0.10) for biliopancreatic limb, and 0.69 (0.63-0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes.

CONCLUSION

The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

A Meta-Analysis of GLP-1 After Roux-En-Y Gastric Bypass: Impact of Surgical Technique and Measurement Strategy

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for diabetes. Glucagon-like peptide-1 (GLP-1) is a gut hormone that is important to glucose homeostasis.

OBJECTIVE

This study aimed to assess GLP-1 level and its predictors after RYGB.

METHODS

The study design was a meta-analysis. The data sources were MEDLINE, EMBASE, Web of Science, and the Cochrane Databases. The study selection composed of studies with pre- and post-RYGB levels. The main outcomes were as follows: Primary outcome was the change in postprandial GLP-1 levels after RYGB. Secondary outcomes included the changes in fasting glucose, fasting insulin, and fasting GLP-1 levels after RYGB. Meta-regression to determine predictors of changes in GLP-1 levels was performed. Outcomes were reported using Hedge's g.

RESULTS

Twenty-four studies with 368 patients were included. Postprandial GLP-1 levels increased after RYGB (Hedge's g = 1.29, p < 0.0001), while fasting GLP-1 did not change (p = 0.23). Peak postprandial GLP-1 levels gave the most consistent results (I ² = 9.11). Fasting glucose and insulin levels decreased after RYGB (p < 0.0001). Roux limb length was a significant predictor for amount of GLP-1 increase (β = - 0.01, p = 0.02). Diabetes status, amount of weight loss, length of biliopancreatic limb, and time of measurement were not significant predictors (p > 0.05).

CONCLUSION

Postprandial GLP-1 levels increase after RYGB, while fasting levels remain unchanged. Shorter Roux limb length is associated with greater increase in postprandial GLP-1, which may lead to better glycemic control in this population.

A Prospective Single-Arm Trial of Modified Long Biliopancreatic and Short Alimentary Limbs Roux-En-Y Gastric Bypass in Type 2 Diabetes Patients with Mild Obesity

BACKGROUND

Type-2 diabetes (T2D) patients with body mass index (BMI) below 35 kg/m² carry lower remission rates than severely obese T2D individuals submitted to "standard limb lengths" Roux-en-Y gastric bypass (RYGB). Mild-obese patients appear to have more severe forms of T2D, where the mechanisms of glycemic control after a standard-RYGB may be insufficient. The elongation of the biliopancreatic limb may lead to greater stimulation of the distal intestine, alterations in bile acids and intestinal microbiota, among other mechanisms, leading to better metabolic outcomes. The aim of this study is to evaluate the safety and efficacy of the RYGB with a biliopancreatic limb of 200 cm in the control of T2D in patients with BMI 30-35 kg/m².

METHODS

From January 2011 to May 2015, 102 T2D patients with BMI from 30 to 34.9 kg/m² underwent laparoscopic RYGB with the biliopancreatic-limb of 200 cm and the alimentary-limb of 50 cm.

RESULTS

There were no deaths or reoperations. The mean follow-up was 28.1 months. The mean BMI dropped from 32.5 to 25.1 kg/m², while the mean fasting glucose decreased from 182.9 to 89.8 mg/dl and the mean glycated hemoglobin (HbA1c) went from 8.7 to 5.2%. During follow-up, 92.2% had their T2D under complete control (HbA1c < 6%, no anti-diabetic medications), while 7.8% were under partial control. Control of hypertension and dyslipidemia were 89.4 and 85.5%, respectively. No patient developed hypoalbuminemia, and there were mild micronutrient deficiencies.

CONCLUSIONS

RYGB with long-biliopancreatic and short-alimentary limbs is safe and seems effective in achieving complete control of T2D in patients with BMIs between 30 and 35 kg/m².

Long-limb length difference had no effect on outcomes of laparoscopic Roux-en-Y gastric bypass surgery for obese Chinese patients with type 2 diabetes mellitus: A CONSORT compliant article

Bariatric surgery is effective in treating different components of metabolic syndrome including obesity, type 2 diabetes mellitus (T2DM), and hyperlipidemia. But there is no consensus on the ideal biliopancreatic and Roux limb length. This study aimed to explore the effect of biliopancreatic limb and Roux limb lengths during laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on weight loss and T2DM control.We studied the clinical records of 58 patients with metabolic syndrome, T2DM, and body mass index (BMI) 32 to 50 kg/m who underwent LRYGB in our hospital. The short limb group (Group A) underwent LRYGB with a limb length of 160 to 200 cm (n = 31) and the long limb group (Group B) underwent LRYGB with a limb length of 210 to 240 cm (n = 27) were compared.The occurrence of acute or chronic internal hernia in Group B was higher than that in Group A (P = .026). Twelve months after surgery, patients from the 2 groups were also observed with reduction in BMI, percent excess weight loss (EWL), preoperative FPG, and HbA1c as compared with these indicators before surgery. However, the differences of these indicators between 2 groups were not significant at the time point of before and 3, 6, 12 months after surgery.LRYGB had significant effects on weight loss and diabetes control in obese T2DM patients. However, there was no significant difference in the short term on weight loss and diabetes control in the patients receiving different limb lengths.

Does length of common limb influence remission of diabetes? Short-term results

BACKGROUND:

Despite strict patient selection criteria, diabetes remission is not seen in all patients after gastric bypass. Can length of the common limb influence diabetes remission?

AIM:

To find if any correlation exists between the length of the common limb and remission of diabetes.

STUDY DESIGN:

Prospective study.

MATERIALS AND METHODS:

Twenty-five consecutive patients with Type II diabetes mellitus and a fasting C-peptide >1 ng/ml who underwent laparoscopic Roux-en-y gastric bypass were included. All patients had standard limb lengths and length of the common limb was measured in all patients. Patients were followed up and glycated haemoglobin (HbA1c) was repeated at 6 months postoperatively. Pre- and postoperative HbA1c were then correlated with the lengths of common limb to look for any relation.

STATISTICAL ANALYSIS:

Descriptive and inferential statistical analysis, analysis of variance (ANOVA).

RESULTS:

Of the 25 patients, 15 were females and 10 were males. The mean age was 44.16 years and the mean body mass index (BMI) was 43.96 kg/m². Preoperative HbA1c varied from 5.8 to 12.3%. Length of the common limb varied from 210 to 790 cm (mean 470.4 cm). HbA1c at 6 months ranged from 4.8 to 7.7% (mean 5.81%). On comparison of preoperative and 6 months postoperative HbA1c and correlating with the length of common limb, we found that patients with a common limb of length <600 cm had a statistically significant improvement in HbA1c compared to those with >600 cm length (P = 0.004).

CONCLUSION:

A shorter common limb does appear to have better chances of resolution of Type II diabetes mellitus in our study, thus paving the way for further studies.

Laparoscopic Roux-en-Y gastric bypass with ileal transposition - an alternative surgical treatment for type 2 diabetes mellitus and gastroesophageal reflux

Currently, type 2 diabetes mellitus (T2DM) is considered as a gastrointestinal disease. Numerous studies have demonstrated that bariatric operations ameliorate T2DM significantly. The laparoscopic Roux-en-Y gastric bypass (L-RYGB) is considered as the gold standard procedure. We aimed to evaluate the feasibility and impact of L-RYGB with ileal transposition (or interposition) on diabetes resolution in a patient who has not benefited from any medical therapy, with its additional effect on the amelioration of gastroesophageal reflux disease. The patient was a 38-year-old diabetic woman with uncontrolled blood glucose despite medical treatment, with additional gastroesophageal reflux disease. Following the procedure, her biochemical parameters and reflux symptoms improved significantly within 10 months. We think that L-RYGB with ileal transposition may be easily employed to gain a maximum effect in diabetics with adverse prognosis. This technique may be an alternative in the treatment of type 2 diabetic patients with gastroesophageal reflux.

A prospective evaluation of the influence of three bariatric procedures on insulin resistance improvement. Should the extent of undiluted bile transit be considered a key postoperative factor altering glucose metabolism?

INTRODUCTION

Insulin resistance (IR), the essential step in development of type 2 diabetes mellitus (T2DM), resolves quickly after bariatric surgery, but the effectiveness depends on the type of the procedure. Although the long-term influence on IR improvement is well documented, the mechanisms of the ultra-fast response after restrictive and bypass procedures require explanation.

AIM

To determine IR evolution from the initial preparative period to 6 months after the operation, exposing the rapid postoperative response while comparing the 3 bariatric methods, with the belief that the metabolic effect may be correlated with anatomical combinations.

MATERIAL AND METHODS

From January to December, 2013, a cohort of severely obese, insulin resistant individuals recruited to the prospective study underwent laparoscopic sleeve gastrectomy (SG-30), Roux-en-Y gastric bypass (RYGB-30) and one-anastomosis gastric bypass (OAGB-30). Main laboratory parameters of glucose metabolism were evaluated in fasting patients preoperatively, 4 days and 1, 3 and 6 months after surgery.

RESULTS

Within the whole observation period the most significant improvement in homeostasis model assessment for IR (HOMA-IR) was observed in the first 4 days after each operation. The decrease of HOMA-IR was higher (p < 0.0001) in gastric bypass groups than in patients after SG (-41%). The difference between bypass groups favors OAGB over RYGB (63 vs. -56%, p = 0.0489).

CONCLUSIONS

Among all bariatric management factors, operation type is the most important in IR improvement. The significant difference in response after SG vs. RYGB and OAGB supports the concept of metabolic competence of duodeno-jejunal exclusion. Altered bile flow after duodeno-jejunal exclusion may be responsible for enhanced glucose metabolism improvement.

Dynamics of type 2 diabetes mellitus laboratory remission after Roux-en-Y gastric bypass in patients with body mass index lower than 35 kg/m(2) and higher than 35 kg/m(2) in a 3-year observation period

Introduction

Bariatric surgery as treatment of type 2 diabetes mellitus (T2DM) in morbidly obese patients is becoming common. Although a large number of studies demonstrating high efficacy of bariatric methods in diabetics with body mass index (BMI) < 35 kg/m² have been published, this promising solution is still not accepted enough even in the era of a diabetes offensive.

Aim

To analyze the dynamics of T2DM remission in patients with BMI < 35 kg/m² and > 35 kg/m² after Roux-en-Y gastric bypass (RYGB).

Material and methods

Data of 30 patients with BMI < 35 kg/m² and 82 with BMI > 35 kg/m² who underwent RYGB between 2007 and 2010 were collected from a prospectively designed database. The laboratory resolution of T2DM was determined by fasting plasma glucose (FPG ≤ 100 mg/dl) and glycosylated hemoglobin (HbA_1c ≤ 6%).

Results

The T2DM regression was observed in 80% of the patients with BMI < 35 kg/m² and 83% in a group with BMI > 35 kg/m² 1 year after RYGB and about 80% 2 and 3 years after the operation in both groups. Normalization of average HbA_1c and FPG was observed in the BMI > 35 kg/m² group after 3 months, while in the BMI < 35 kg/m² group it was reached 6 months postoperatively. Changes in main markers of T2DM were parallel with the BMI decrease 3–12 months after RYGB, but early resolution in some patients was observed independently of weight loss.

Conclusions

The mid-term observation of patients after RYGB revealed the laboratory remission of T2DM. Ultimate evaluation of T2DM markers 3 years after surgery demonstrates high effectiveness of RYGB in managing T2DM in both groups.